Registration Form Please, fill in the form below and click submit to process your child's registration.  Submit one form for each child as needed......   STUDENT'S INFORMATION: Enter child's name: Last name   First name Middle initial            Sex Date of birth  Indicate type of enrollment you want for the child: Full Time               Part Time FAMILY INFORMATION: Please provide the following contact information for child's parents:         Mother's Information: Last name   First name  Middle initial Street address Address(cont.) City   State     Zip code  Work Phone       Home Phone   FAX       E-mail    URL         Father's Information: Last name   First name  Middle initial Street address Address(cont.) City   State     Zip code  Work Phone       Home Phone   FAX       E-mail    URL MEDICAL INFORMATION I hereby grant permission for the staff of A - Z Child Development to contact the following medical personnel to obtain emergency medical care if warranted. Doctor Address:Phone: Doctor Address:Phone: Doctor Address:Phone:  Hospital Preference Please list allegies, special medical or dietary needs, or other areas of concern:   CONTACTS: Child will be released only to the custodial parent or legal guardian and the persons listed below.  The following people will also be contacted and are authorized to pick up the child from the Center in case of illness, accident, or emergency, if for some reason the costodial parent or legal guardian cannot be reached: Name Address:                             Work Phone:     Home Phone: Name Address:                             Work Phone:     Home Phone: Name Address:                             Work Phone:     Home Phone: Name Address:                             Work Phone:     Home Phone: Name Address:                             Work Phone:     Home Phone: Name Address:                             Work Phone:     Home Phone:       Custody:         Mother               Father             Both               Other Helpful information about your child:   Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. Section 402.3125(5), F.S., requires that parents recieve a copy of the Child Care Facility Brochure, "KNOW YOUR CHILD CARE CENTER". Section 65C-22.006(4)(c)(2)., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility. Be sure that all information you provide on this registration form is correct, accurate, and can be substantiated. By checking the "I accept" option below, you certify that you have visited our website, particularly "know your child care center" and "disciplinary policy" and that you have review the contents of the documents and understand them as presented.        "I accept"               I do not accept, I will procure information personally